Back Index Form

Patient's Name(Required)

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Email(Required)

Date of Birth(Required)

This questionnaire will give your provider information about how your back condition affects your everyday life. Please answer every section by marking the one statement that applies to you. If two or more statements in one section apply, please mark the one statement that most closely describes your problem.

Pain Intensity

0 - The pain comes and goes and is very mild.

1 - The pain is mild and does not vary much.

2 - The pain comes and goes and is moderate.

3 - The pain is moderate and does not vary much.

4 - The pain comes and goes and is very severe.

5 - The pain is very severe and does not vary much.

Personal Care

0 - I do not have to change my way of washing or dressing in order to avoid pain.

1 - I do not normally change my way of washing or dressing even though it causes some pain.

2 - Washing and dressing increases the pain but I manage not to change my way of doing it.

3 - Washing and dressing increases the pain and I find it necessary to change my way of doing it.

4 - Because of the pain I am unable to do some washing and dressing without help.

5 - Because of the pain I am unable to do any washing and dressing without help.

Sleeping

0 - I get no pain in bed.

1 - I get pain in bed but it does not prevent me from sleeping well.

2 - Because of pain my normal sleep is reduced by less than 25%.

3 - Because of pain my normal sleep is reduced by less than 50%.

4 - Because of pain my normal sleep is reduced by less than 75%.

5 - Pain prevents me from sleeping at all.

Lifting

0- I can lift heavy weights without extra pain.

1 - I can lift heavy weights but it causes extra pain.

2 - Pain prevents me from lifting heavy weights off the floor.

3 - Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned (e.g., on a table).

4 - Pain prevents me from lifting heavy weights off the floor, but I can manage light to medium weights if they are conveniently positioned.

5 - I can only lift very light weights.

Sitting

0 - I can sit in any chair as long as I like.

1 - I can only sit in my favorite chair as long as I like.

2 - Pain prevents me from sitting more than 1 hour.

3 - Pain prevents me from sitting more than 1/2 hour.

4 - Pain prevents me from sitting more than 10 minutes.

5 - I avoid sitting because it increases pain immediately.

Traveling

0 - I get no pain while traveling.

1 - I get some pain while traveling but none of my usual forms of travel make it worse.

2 - I get extra pain while traveling but it does not cause me to seek alternate forms of travel.

3 - I get extra pain while traveling which causes me to seek alternate forms of travel.

4 - Pain restricts all forms of travel except that done while lying down.

5 - Pain restricts all forms of travel.

Standing

0 - I can stand as long as I want without pain.

1 - I have some pain while standing but it does not increase with time.

2 - I cannot stand for longer than 1 hour without increasing pain.

3 - I cannot stand for longer than 1/2 hour without increasing pain.

4 - I cannot stand for longer than 10 minutes without increasing pain.

5 - I avoid standing because it increases pain immediately.

Social Life

0 - My social life is normal and gives me no extra pain.

1 - My social life is normal but increases the degree of pain.

2 - Pain has no significant affect on my social life apart from limiting my more energetic interests (e.g., dancing, etc).

3 - Pain has restricted my social life and I do not go out very often.

4 - Pain has restricted my social life to my home.

5 - I have hardly any social life because of the pain.

Walking

0 - I have no pain while walking.

1 - I have some pain while walking but it doesn’t increase with distance.

2 - I cannot walk more than 1 mile without increasing pain.

3 - I cannot walk more than 1/2 mile without increasing pain.

4 - I cannot walk more than 1/4 mile without increasing pain.

5 - I cannot walk at all without increasing pain.

Changing degree of pain

0 - My pain is rapidly getting better.

1 - My pain fluctuates but overall is definitely getting better.

2 - My pain seems to be getting better but improvement is slow.

3 - My pain is neither getting better or worse.

4 - My pain is gradually worsening.

5 - My pain is rapidly worsening.

Index Score = [Sum of all statements selected / (# of sections with a statement selected x 5)] x 100

Symptoms began on:(Required)

Briefly describe your symptoms:(Required)

How did your symptoms start?(Required)

Average pain intensity the last 24 hours(Required)

0 = no pain and 10 = worst pain

Average pain intensity the last week(Required)

0 = no pain and 10 = worst pain

How often do you experience your symptoms?(Required)

1 - Constantly (76%-100% of the time)

2 - Frequently (51%-75% of the time)

3 - Occasionally (26% - 50% of the time)

4 - Intermittently (0%-25% of the time)

How much have your symptoms interfered with your usual daily activities?(Required)

1 - Not at all

2 - A little bit

3 - Moderately

4 - Quite a bit

5 - Extremely

(including both work outside the home and housework)

How is your condition changing, since care began at this facility?(Required)

0 - N/A — This is the initial visit

1 - Much worse

2 - Worse

3 - A little worse

4 - No change

5 - A little bit better

6 - Beter

7 - Much better

In general, would you say your overall health right now is...(Required)

1 - Excellent

2 - Very good

3 - Good

4 - Fair

5 - Poor

Singer's Name(Required)

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